Patient Safety & Leadership Rounds (PSLR) ver.2

• Site conducted

  Select

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Survey Team

ENVIRONMENT OF CARE

General Safety

• Sinks: Sinks secured / locked and no items stored under sinks?

  Yes

  No

  N/A

• Equipment / Furniture:<br> * All equipment/furniture in good condition/functional and no broken equipment or furniture stored on the patient care units.<br> * Coverings are intact - no rips, cracks, chipped, stains or repairs needed (broken).

  Yes

  No

  N/A

• Solid Waste: Appropriate items in general waste receptacles.

  Yes

  No

  N/A

• Soiled Utility: Appropriate items in linen storage bins, bin capacity (32 US gallons) and maximum quantity enforced (2 bins per 10' x 10' room).

  Yes

  No

  N/A

• Refrigerators Patient Use: Contain only items permitted for placement/storage i.e., specimens, medications, formulas, or patient food items

  Yes

  No

  N/A

• Refrigerators Staff Use: Personal items are clearly labeled, use of shopping/plastic bags are strictly prohibited, and refrigerator is well maintained and kept clean at all times

  Yes

  No

  N/A

• Refrigerator Temperature Monitoring: Temperature logs are completed daily and action is taken and documented when temperature is out of range

  Yes

  No

  N/A

• Lighting: Is lighting suitable for patient care, treatment and services

  Yes

  No

  N/A

• Air Quality: Unit air is free from offensive odors

  Yes

  No

  N/A

• Compressed Gas Cylinders: Medical oxygen/compressed gas cylinders stored in designated storage location, all cylinders in use are used with proper cart or secured to prevent falling/toppling

  Yes

  No

  N/A

• Compressed Gas Cylinders: Medical oxygen/compressed gas cylinders are stored with full and empty cylinders separated and does not exceed the maximum of 12 E cylinders per smoke compartment

  Yes

  No

  N/A

• Compressed Gas Cylinders: Empty medical oxygen/compressed gas cylinders are labeled “empty”/have tags indicating appropriate label (full, in-use, empty)

  Yes

  No

  N/A

• Ceiling Tiles: All ceiling tiles are in place, clean, dry, with no stains or holes / penetrations

  Yes

  No

  N/A

• Appliances and Patient Equipment/Products: All electric or electronic staff and patient furnished appliances or consumer products have been inspected, approved for use, and labeled accordingly prior to use based on known area restrictions

  Yes

  No

  N/A

• Power Strips: Power strips used on non-patient care equipment outside of patient care vicinity UL listed

  Yes

  No

  N/A

Medical Equipment

• Medical Equipment: All equipment in good condition and operational

  Yes

  No

  N/A

• Medical Equipment Safety & Maintenance Inspection Tags: All equipment safety and maintenance inspection tags in place and current

  Yes

  No

  N/A

• Medical Equipment Maintenance: Staff can identify whether and when medical equipment is due or past due for service

  Yes

  No

  N/A

• Medical Equipment Failure Procedures: Staff can demonstrate or describe emergency procedures to follow in the event of medical equipment failure

  Yes

  No

  N/A

• Medical Equipment Incidents: Procedures for reporting patient device malfunction and equipment incident problems are known to the staff and reported to Biomed

  Yes

  No

  N/A

• Blanket Warmers: Set to maintain temp of 130, temperature logs completed routinely and out of range temperature readings addressed as required

  Yes

  No

  N/A

• Nurse Call: Nurse call system, lights, and call cords in place and functional

  Yes

  No

  N/A

• Clinical & Equipment Alarms: Staff can describe or demonstrate checking and documenting clinical alarms and identify which critical equipment have alarms

  Yes

  No

  N/A

• Equipment Power Cords: All power plugs are 3 pronged for patient care equipment and cords are in good visual condition

  Yes

  No

  N/A

Utilities

• Power Strips: Power strips are only used on moveable patient care equipment, are permanently attached to the equipment, and are UL 1363A 0r UL 60601-1

  Yes

  No

  N/A

• Electrical Panels: All electrical panels are accessible maintaining a 36” clearance in front of panel(s) and panels are secured/locked to prevent tampering

  Yes

  No

  N/A

• Emergency Outlets: Staff can identify emergency (red) electrical outlets/receptacles

  Yes

  No

  N/A

• Medical Gas Valves: All medical gas valves are properly labelled (by zones)

  Yes

  No

  N/A

• Medical Gas Valves: Staff can describe or demonstrate medical gas zone valves, rooms they serve, and who is authorized to operate the valves

  Yes

  No

  N/A

• Air Quality: Air pressure monitoring devices are not in alarm condition and devices are operating correctly

  Yes

  No

  N/A

• Restrooms: Showers, sinks and water closets are free from leaks

  Yes

  No

  N/A

• Electrical Outlets and Switches: Lights switch covers and outlet receptacles in place with no exposed wires

  Yes

  No

  N/A

• Electrical Outlets: Electrical outlets and receptacles within 6 ft of a water source (sink) has GFCI protection.

  Yes

  No

  N/A

Hazardous Materials & Waste

• Staff Training: All staff have completed universal precaution, blood borne pathogen, and hazard communication training and training records are readily available

  Yes

  No

  N/A

• Medical Waste: Only appropriate/approved items placed in biohazard waste receptacles

  Yes

  No

  N/A

• Hazardous Rooms/Areas: Secured/locked

  Yes

  No

  N/A

• Hazardous Labeling: Biohazard receptacles/containers properly labeled. Hazardous substances properly labeled, stored and handled.

  Yes

  No

  N/A

• Red Bags: Staff have been educated on what materials can and/or cannot be placed into the red bags.

  Yes

  No

  N/A

• Sharps: Sharp containers not overfilled, no more than ¾ full

  Yes

  No

  N/A

• Eyewash/Shower Stations: Staff know the location of the nearest emergency eye wash/shower station and weekly inspection tags/logs present and up to date

  Yes

  No

  N/A

• Safety Data Sheets: Staff know where to find SDS and inventory listing is current

  Yes

  No

  N/A

• Spill Response: Staff are aware of department specific spill response procedures

  Yes

  No

  N/A

• Flammable and Corrosives: Properly segregated, and properly stored with SDS readily available

  Yes

  No

  N/A

• Chemical Labeling: Staff are aware of properly labeling secondary containers used for hazardous chemical and all bottles/containers are properly labelled

  Yes

  No

  N/A

• Chemical Use: Staff are knowledgeable on appropriate selection, handling, storing, transporting, use, and disposal processes for hazardous materials

  Yes

  No

  N/A

• Hazardous Medications: Hazardous medication are properly disposed

  Yes

  No

  N/A

Fire Safety / Life Safety

• PPE Availability: Appropriate personal protective equipment is readily available with adequate quantities and in good condition

  Yes

  No

  N/A

• Fire Sprinklers: Sprinkler heads are free from excessive dust/paint and all sprinklers have the appropriate escutcheon plates/rings

  Yes

  No

  N/A

• Exits & Smoke Compartments: Staff know where nearest exit(s) and adjacent smoke compartment(s) are located, exit signs are lit and clearly visible

  Yes

  No

  N/A

• Means of Egress: Fire exits are clearly marked, unlocked from inside, aisles/corridors are clear without obstructions

  Yes

  No

  N/A

• Means of Egress: Hallway/Corridor clearance – no equipment not in active use is permitted in the hallway. Permitted items must be staged only on one side.

  Yes

  No

  N/A

• Fire Doors: All doors operate as designed, have positive latching, propped open doors and paper signs attached to doors is strictly prohibited

  Yes

  No

  N/A

• Fire Extinguishers: Fire extinguishers are in proper place, safety inspection tags in place and current, clear access unobstructed access to extinguishers

  Yes

  No

  N/A

• Walls: Walls are free from holes/penetrations and cleanliness is maintained

  Yes

  No

  N/A

• Exit Signs: Exit signs are properly mounted, clearly visible, and illuminated.

  Yes

  No

  N/A

• Storage Rooms: Combustible materials are properly stored and kept to a minimum

  Yes

  No

  N/A

• Storage Rooms: Materials stored on shelves comply with the 18” fire sprinkler clearance requirement, items stored directly is monitored and prohibited

  Yes

  No

  N/A

• Fire Drills: Staff understand the acronym of RACE & PASS

  Yes

  No

  N/A

• Fire Response Plan: Staff are knowledgeable on location of fire alarm pull stations, primary fire exits, and location of evacuation chairs

  Yes

  No

  N/A

• Medical Gas Shut Off Valves: Staff aware of locations of emergency shut off valves for medical gases and who is authorized to turn off supply

  Yes

  No

  N/A

• Fire Response Plan: Fire alarm pull stations, fire extinguishers, medical gas shutoff valves have clear access and not blocked or obstructed

  Yes

  No

  N/A

Security

• Corridors: Corridors are free from obstruction. Work Station on Wheels (WOWs) are removed from the egress corridors in the event of fire alarm activation(s). 30 minute rule applies.

  Yes

  No

  N/A

• Security Access Controls Systems: All access controls systems (swipe cards) and ADA disability push plates/auto doors, are functioning properly

  Yes

  No

  N/A

• Security Access Controls Systems: Maglocks and motion detectors are functioning properly

  Yes

  No

  N/A

• Employee ID Badges: All employees are wearing identification badges and all badges are clearly visible

  Yes

  No

  N/A

• Visitor/Contractors Daily Pass Program: All visitors and contractors are wearing appropriate tags and are monitored for compliance

  Yes

  No

  N/A

• Security Request Procedure: Employees can demonstrate how to request security and how to report security and safety incidents using the Incident Reporting System (IR)

  Yes

  No

  N/A

• Restricted Areas: Restricted areas/controlled access rooms/areas are properly identified and secured

  Yes

  No

  N/A

• Medication Rooms: Medication rooms are continuously monitored and secured

  Yes

  No

  N/A

• Security Alarms: Security alarms at exit doors are functioning properly

  Yes

  No

  N/A

• Crash Carts: Crash carts are secured when not in use

  Yes

  No

  N/A

• Exit Doors: Exit doors close and lock properly

  Yes

  No

  N/A

EMERGENCY MANAGEMENT

Emergency Preparedness

• Emergency References: Emergency reference guides are available and staff know where to locate/find them.

  Yes

  No

  N/A

• Staff aware of GRMC's Emergency Operation Plans (EOP) & response procedures and/or know where to locate the EOP

  Yes

  No

  N/A

Emergency Codes (Staff Knowledge)

• Staff know what a CODE RED is. (Fire)

  Yes

  No

  N/A

• Staff knows unit specific response to CODE RED?

  Yes

  No

  N/A

• Staff know what a CODE YELLOW is. (Utility Failure)

  Yes

  No

  N/A

• Staff knows unit specific response to CODE YELLOW?

  Yes

  No

  N/A

• Staff know what a CODE GREEN is. (Elopement)

  Yes

  No

  N/A

• Staff knows unit specific response to CODE GREEN?

  Yes

  No

  N/A

• Staff know what a CODE BLUE is. (Medical Emergency)

  Yes

  No

  N/A

• Staff knows unit specific response to CODE BLUE?

  Yes

  No

  N/A

• Staff know what a CODE GRAY is. (Disruptive Person)

  Yes

  No

  N/A

• Staff knows unit specific response to CODE GRAY?

  Yes

  No

  N/A

• Staff know what a CODE BLACK is. (Bomb Threat)

  Yes

  No

  N/A

• Staff knows unit specific response to CODE BLACK?

  Yes

  No

  N/A

INFECTION CONTROL

Patient Rooms

• Horizontal and vertical surfaces are clean; Nothing on window sills

  Yes

  No

  N/A

• INFECTION CONTROL

  Yes

  No

  N/A

• If cleaning checklist is used, is it signed off

  Yes

  No

  N/A

• Trash cans not overflowing

  Yes

  No

  N/A

• Bathroom is clean

  Yes

  No

  N/A

• Hand hygiene products available, PPE available as needed

  Yes

  No

  N/A

• No overfilled sharps containers

  Yes

  No

  N/A

• No open sterile saline or sterile water left in room

  Yes

  No

  N/A

• Privacy curtains tagged with cleaning schedule (hung & change date)

  Yes

  No

  N/A

Isolation Rooms

• Appropriate signage in place

  Yes

  No

  N/A

• PPE stocked, red bags easily accessible

  Yes

  No

  N/A

• Trash and linen handled per policy

  Yes

  No

  N/A

• Appropriate PPE used by staff

  Yes

  No

  N/A

• Appropriate patient/family education

  Yes

  No

  N/A

• Airborne precautions:<br> Door is closed<br> Negative pressure is monitored<br> Appropriate air exchange

  Yes

  No

  N/A

Hand Hygiene

• Sinks for handwashing are appropriately stocked with soap, paper towels, trash cans

  Yes

  No

  N/A

• Sinks are available in patient’s room and all areas as needed

  Yes

  No

  N/A

• Alcohol hand sanitizers are available in all areas as needed and not expired

  Yes

  No

  N/A

• Placement of alcohol hand sanitizer is compliant with safety recommendations

  Yes

  No

  N/A

• Handwashing/hand hygiene is monitored by staff for compliance

  Yes

  No

  N/A

• No unapproved lotions

  Yes

  No

  N/A

Nourishment Room

• Door to room is labeled

  Yes

  No

  N/A

• Refrigerator has single use (medications, foods, specimens)

  Yes

  No

  N/A

• Items are appropriately labeled, not expired

  Yes

  No

  N/A

• Refrigerator is clean and defrosted (if necessary)

  Yes

  No

  N/A

• Ice machine clean

  Yes

  No

  N/A

Linen (Clean)

• Door to room is labeled

  Yes

  No

  N/A

• Linens are in good condition

  Yes

  No

  N/A

• Stored on covered cart or in linen room

  Yes

  No

  N/A

• Covered for transport

  Yes

  No

  N/A

Linen (Soiled)

• Door to room is labeled

  Yes

  No

  N/A

• In hamper with impervious liner or hamper is cleaned on specific schedule

  Yes

  No

  N/A

• Hamper is covered

  Yes

  No

  N/A

• Soiled linen covered for transport

  Yes

  No

  N/A

• Soiled linen is bagged at bedside

  Yes

  No

  N/A

• Removed from unit on specified schedule

  Yes

  No

  N/A

Administrative Areas: Offices, Conference Rooms, Nurses Station

• Horizontal and vertical surfaces are clean

  Yes

  No

  N/A

• Trash cans are not overflowing

  Yes

  No

  N/A

• Uncluttered

  Yes

  No

  N/A

• Bathrooms are clean, hand hygiene products are available

  Yes

  No

  N/A

Hazardous Materials & Biomedical Waste

• Storage areas have appropriate signage

  Yes

  No

  N/A

• Biomedical waste is handled per policy, picked up for transport on specified schedule

  Yes

  No

  N/A

• Appropriate sharps containers in use

  Yes

  No

  N/A

• Sharps containers no more than ¾ full

  Yes

  No

  N/A

• Sharps containers secured for transport

  Yes

  No

  N/A

• Locate blood, chemical spill kit

  Yes

  No

  N/A

Cleaning & Disinfection

• Medical equipment in good working condition

  Yes

  No

  N/A

• Appropriate processes in place for low level cleaning and disinfection

  Yes

  No

  N/A

• Employee protection measures are implemented

  Yes

  No

  N/A

• Preventive maintenance program in place

  Yes

  No

  N/A

Supply / Storage Rooms

• Door to room is labeled

  Yes

  No

  N/A

• Storage areas are clean and uncluttered

  Yes

  No

  N/A

• Supplies are at least 18” from sprinkler heads

  Yes

  No

  N/A

• Supplies are stored off the floor

  Yes

  No

  N/A

• No corrugated and outside shipping boxes

  Yes

  No

  N/A

• General Supplies or Patient care supplies not expired, damaged, soiled, or compromised.

  Yes

  No

  N/A

• Plastic/impermeable liners are present on all bottom shelves

  Yes

  No

  N/A

Clean Utility Room

• Door to room is labeled

  Yes

  No

  N/A

• Environment is clean

  Yes

  No

  N/A

• Clean equipment is tagged/bagged as ready to use

  Yes

  No

  N/A

• No storage of patient personal belongings

  Yes

  No

  N/A

• No corrugated and outside shipping boxes

  Yes

  No

  N/A

• All supplies off the floor

  Yes

  No

  N/A

• Supplies are not stored under sinks

  Yes

  No

  N/A

Soiled Utility Room

• Door to room is labeled

  Yes

  No

  N/A

• Biohazard symbol on door if biomedical waste in room

  Yes

  No

  N/A

• Soiled linen in hamper with impervious liner or hamper is cleaned on specific schedule

  Yes

  No

  N/A

• Room is uncluttered / Appropriate use of utility room

  Yes

  No

  N/A

• Clean supplies not in room

  Yes

  No

  N/A

• Appropriate PPE available

  Yes

  No

  N/A

Waiting Areas

• Horizontal and vertical surfaces are clean

  Yes

  No

  N/A

• Trash is not overflowing

  Yes

  No

  N/A

• Area is uncluttered

  Yes

  No

  N/A

• If appropriate, supplies for respiratory hygiene available and posted instructions in place

  Yes

  No

  N/A

Public / Patient Restrooms

• All surfaces are clean

  Yes

  No

  N/A

• Handwashing supplies are available and not expired

  Yes

  No

  N/A

• Trash is not overflowing

  Yes

  No

  N/A

• Duress / emergency pull cord not wrapped around hand rail.

  Yes

  No

  N/A

• If cleaning checklist is used, appropriately signed off

  Yes

  No

  N/A

Staff Interviews

• Staff are able to locate IC Manual (P&P)

  Yes

  No

  N/A

• Staff can find the Infection Prevention patient/family education and resources

  Yes

  No

  N/A

• Staff know when soap and water for hand hygiene is to be used (pt. w/C. diff/diarrhea/visibly soiled)

  Yes

  No

  N/A

• Staff knowledgeable with the process if they accidentally stick themselves with a needle

  Yes

  No

  N/A

• Observe nail policy enforced (nails less than ¼”, no artificial nails, no cracked or chipped nail polish)

  Yes

  No

  N/A

• Staff knows when someone is in isolation

  Yes

  No

  N/A

• Staff knows how frequently they should clean patient equipment (between patients, visibly soiled at minimum)

  Yes

  No

  N/A

• Staff know about appropriate linen storage

  Yes

  No

  N/A

• Staff aware of who oversees cleaning equipment

  Yes

  No

  N/A

• Staff able to state Standard Prec. Practice for PPE

  Yes

  No

  N/A

• Staff able to state Contact Prec. Practice for PPE

  Yes

  No

  N/A

• Staff able to state Airborne Prec. Practice for PPE

  Yes

  No

  N/A

• Staff able to state Droplet Prec. Practice for PPE

  Yes

  No

  N/A

• Staff knowledgeable about who are allowed in an airborne isolation negative pressure room

  Yes

  No

  N/A

• Staff able to state contact time for Sani-Cloth Wipes (3 minutes)

  Yes

  No

  N/A

• Staff know that gloves should be worn when using Sani-Cloth Wipes

  Yes

  No

  N/A

Medication Room

• Door to room is labeled

  Yes

  No

  N/A

• Horizontal and vertical surfaces are clean

  Yes

  No

  N/A

• Medication refrigerator is clean and tidy

  Yes

  No

  N/A

• No food stored in medication refrigerator

  Yes

  No

  N/A

• Sink for handwashing is appropriately stocked with soap, paper towels, trash cans

  Yes

  No

  N/A

• Admixture areas is clean and uncluttered

  Yes

  No

  N/A

• Pill cutters are clean, free of any medication residual

  Yes

  No

  N/A

• Pill crusher is clean, free of dust

  Yes

  No

  N/A

Janitor Room

• Door to room is labeled

  Yes

  No

  N/A

• Cleaning equipment stored appropriately

  Yes

  No

  N/A

• Environment is clean

  Yes

  No

  N/A

• Room is uncluttered

  Yes

  No

  N/A

Staff Lounge, Staff Food & Drink

• Door to room is labeled

  Yes

  No

  N/A

• Horizontal and vertical surfaces are clean

  Yes

  No

  N/A

• Sink for handwashing is appropriately stocked with soap, paper towels, trash cans

  Yes

  No

  N/A

• Trash is not overflowing

  Yes

  No

  N/A

• Refrigerator is clean and defrosted (if necessary)

  Yes

  No

  N/A

• No food stored over 48 hours. If food is stored, bag is labeled with expiration within 48 hours of storage

  Yes

  No

  N/A

• Microwave is clean

  Yes

  No

  N/A

• Bathroom is clean

  Yes

  No

  N/A

• No crumbs or food is left out to attract ants or other insects like flies or cockroaches

  Yes

  No

  N/A

• Area is uncluttered

  Yes

  No

  N/A

• Food limited to staff lounges, conference rooms, private offices

  Yes

  No

  N/A

• Covered drinks in nursing station limited to low surfaces; no drinks on high surfaces or where drinks can be contaminated (i.e. near specimen pick-up areas)

  Yes

  No

  N/A

• No drinks near patient’s room (i.e. chart racks, WOW’s, shelves between patient rooms)

  Yes

  No

  N/A

INFORMATION MANAGEMENT

Protected Health Information (PHI)

• Confidential Patient Information cannot be seen by unauthorized persons (papers laying around containing PHI)<br>

  Yes

  No

  N/A

• Computer terminals signed off when not in use/not left unattended

  Yes

  No

  N/A

• Patient information is not discussed in public areas where it can be overheard

  Yes

  No

  N/A

• Labels and PHI are obliterated/shredded before discarding in regular trash or appropriately discarded into the shredding bin

  Yes

  No

  N/A

• No clipboards displayed as sign-in sheets when multiple patient names on the list.

  Yes

  No

  N/A

• If fax machine is in public area, patient information is quickly removed.

  Yes

  No

  N/A

NATIONAL PATIENT SAFETY GOALS

Knowledge Quiz

• Staff know what the two acceptable patient identifiers are for GRMC. (answer: Full Name and Date of Birth)

  Yes

  No

  N/A

• Staff know the acceptable time frame to report a critical result. (answer: 15 minutes except from Radiology which is 30 minutes)

  Yes

  No

  N/A

• Staff know how label a multi-dose vial. (answer: Labeled with an expiration date of 28-days from the date opened)

  Yes

  No

  N/A

• Staff know what the primary way to prevent infection. (answer: Hand hygiene/washing hands thoroughly)

  Yes

  No

  N/A

• Staff aware that patients assessed to be at risk for suicide should have the appropriate colored alert on the patient's ID wristband. (answer: Orange colored alert on the wristband)

  Yes

  No

  N/A

• Staff know what a "Time Out" is. (answer: it's a final assessment to verify that you have the correct patient, correct site, and correct procedure prior to incision/surgery)

  Yes

  No

  N/A

PERFORMANCE IMPROVEMENT

• The unit/department's quality improvement dashboard project is posted in unit.

  Yes

  No

  N/A

• Are staff able to speak about their unit specific quality indicators? (Do they know what their quality indicators are?)

  Yes

  No

  N/A

• Are staff aware of the other units/departments' quality indicators or at least know where to find it? (Found in the intranet homepage under "QI SharePoint")

  Yes

  No

  N/A

MEDICATION MANAGEMENT

Medication Room

• Medication refrigerator temperature log is current, in range, and action is documented when a discrepancy is noted.

  Yes

  No

  N/A

• Medication refrigerator: Only contain medications for current patients.

  Yes

  No

  N/A

• Laminar flow hood is used for IV admixture when appropriate.

  Yes

  No

  N/A

• Visual inspection of medication containers/outer plastic wraps for IV solutions: No Issues/Uncompromised.

  Yes

  No

  N/A

• Medications stored appropriately to maintain stability.

  Yes

  No

  N/A

• Medication is appropriately labeled (i.e. expiration dates, directions, etc.)

  Yes

  No

  N/A

• All medications, needles and syringes are secured in locked cabinet or locked room or under constant surveillance.

  Yes

  No

  N/A

• Controlled substances are stored to prevent diversion.

  Yes

  No

  N/A

• Medications, formula, & solutions not expired beyond expiration date.

  Yes

  No

  N/A

• Opened multi-dose vials dated and initialed and is not expired.

  Yes

  No

  N/A

• Syringes are labeled when in use.

  Yes

  No

  N/A

Code Carts

• Code carts are locked and marked with the first drug to expire.

  Yes

  No

  N/A

• Code Carts are checked per policy.

  Yes

  No

  N/A

• Defibrillators are checked per policy.

  Yes

  No

  N/A

• Nothing expired found in/on the code cart.

  Yes

  No

  N/A

• Medication Carts: Doors and drawers are locked.

  Yes

  No

  N/A

• Code Cart is clean not untidy.

  Yes

  No

  N/A

• Oxygen tank is present on cart, secured, not expired, and appropriately labeled (green tag).

  Yes

  No

  N/A

RIGHTS AND RESPONSIBILITIES OF THE INDIVIDUAL

• Patients and families were properly informed of their rights.<br> * Rights and Responsibilities statement

  Yes

  No

  N/A

• Family guides/materials were provided to all families on admissions.

  Yes

  No

  N/A

• The patient was asked if they have a living will or advanced directives upon admission.

  Yes

  No

  N/A

• The patient was provided with an informed consent prior to medical treatment (i.e. surgery). (If applicable, surveyor should request to look at the informed consent with all appropriate elements as well as signatures present.)

  Yes

  No

  N/A

WAIVED TESTING / POINT OF CARE TESTING

• Point of Care testing lab controls documented and control solution labeled & dated. (i.e. Reagents, i Stat analyzes, glucometers, GEMS)

  Yes

  No

  N/A

Point of Care Testing Quality Control

• Consistently and correctly documented<br>

  Yes

  No

  N/A

• Dates not missing initials

  Yes

  No

  N/A

• Performed by qualified person

  Yes

  No

  N/A

• Out of range is followed

  Yes

  No

  N/A

• Logged numbers match bottle ID numbers

  Yes

  No

  N/A

UNITS RESPONSE TO SURVEY TEAM ARRIVAL

• Greet the team with smiles and introductions.

  Yes

  No

  N/A

• Have a space designated for the team to conduct interviews and file reviews.

  Yes

  No

  N/A

• Promptly deliver materials asked for or required for review to the tracer team.

  Yes

  No

  N/A

• No additional comments regarding positive or suboptimal issues observed during the tracer.

  Yes

  No

  N/A

• No additional comments regarding positive or suboptimal issues observed during the tracer.

  Yes

  No

  N/A

• No additional comments regarding positive or suboptimal issues observed during the tracer.

  Yes

  No

  N/A

• No additional comments regarding positive or suboptimal issues observed during the tracer.

  Yes

  No

  N/A

• No additional comments regarding positive or suboptimal issues observed during the tracer.

  Yes

  No

  N/A